Hypoglycaemia in a 5yo dog

RE: Hypoglycaemia in a 5yo dog

gerard mclauchlan — Tue, 12 Jun 2018 14:56:03 GMT

I would ask the lab to run pre and post ACTH aldosterone levels (on same sample you ahve submitted) and if this is low I would start zycortal regardless of electrolytes. There was some recent recommendations regarding this (think dose was 0.8mg/kg rather than 2.2mg/kg). If aldosterone levels normal then monitor lytes every 3 months and if stay normal for 12 months unlikely to develop changes. I still treat with zycortal in cases with low aldosterone regardless of lytes

RE: Hypoglycaemia in a 5yo dog

gerard mclauchlan — Tue, 12 Jun 2018 14:52:12 GMT

[quote user="Martin Atkinson"]

[quote user="Laurence Webb"]

A random basal cortisol would be a fairly cheap screen for hypoadrenocorticism.

[/quote]Not if its atypical glucocorticoid deficiency only which is what we're talking about here.

[/quote]Hi Martin, atypical addisons is glucocorticoid deficiency only so dogs lack the electrolyte changes seen with mineralocorticoid deficiency. Basal cortisol >55 mmol/l would exclude hypoadrenocortisicm.

RE: Hypoglycaemia in a 5yo dog

Beats — Mon, 11 Jun 2018 20:55:05 GMT

The electrolytes go within a year in my experience, so worth monitoring every 3 months or so. Presumably more complete adrenocortical destruction with time leading to lack of aldosterone also eventually?

(Interestingly, I've had case go the other way too, normal cortisol and no aldosterone, I looked into importing DOCP at the time and was too expensive, so got florinef... fast forward a good number of years and it's now on preds and DOCP, the only case that I was in any way amused to be changing over )

RE: Hypoglycaemia in a 5yo dog

Virginia Campbell — Mon, 07 May 2018 21:39:29 GMT

We had a mini poodle about 5kg in the practice ages ago that was a "normal" Addisonian and I think she was only on half a 1mg pred daily for years. Mind you she was on Florinef too so getting some glucocortocoid activity from that too. I remember another dog, a Westie with persistently low bg+exercise intolerance, think they couldn't afford dx so I told them prob insulinoma, we'll keep it on pred till it needs euthed and it lived for years. So in retrospect maybe atypical Addisons as I suppose insulinoma should have killed it before then. Think it was on 1mg pred daily. Low doses seem to do the job.

RE: Hypoglycaemia in a 5yo dog

Thomas Johnson — Fri, 04 May 2018 12:14:27 GMT

[quote user="Edward Jones"]

A bit of a stab in the dark - if there was a mineralocorticoid deficiency wouldn't it have Na:K ratio abnormalities too? i.e. microdosing prednisolone is probably sufficient.

[/quote]

I agree, I would hope to manage this dog on just low dose prednisolone.

[quote user="Edward Jones"]

edit: also tetracosactide shouldn't cost £40, should it?

[/quote]

£268.91 plus VAT for 8 vials of Tetracosactide from Henry Schein, or £58.20 plus VAT for a single Synacthen vial.

RE: Hypoglycaemia in a 5yo dog

Edward Jones — Fri, 04 May 2018 11:37:28 GMT

A bit of a stab in the dark - if there was a mineralocorticoid deficiency wouldn't it have Na:K ratio abnormalities too? i.e. microdosing prednisolone is probably sufficient.

edit: also tetracosactide shouldn't cost £40, should it?

RE: Hypoglycaemia in a 5yo dog

David Mills — Thu, 03 May 2018 23:27:53 GMT

[quote user="Anthony Dennison"]

[quote user="David Mills"]

Update on this case. Stable on preds but looking iatrogenic Cushing. Stopped for 2 weeks, return of lethargy but not hypoglycemic.

ACTH stim

Base <27

Post <27

Electrolytes normal.

So looking v much like atypical Addisons.

[/quote]

Also, although you stopped the preds for 2 weeks as there were signs of Iatrogenic Cushings could this still be adrenal suppression from treatment?

[/quote]

Yes checked this today and actually off for 4 weeks, was on about 0.5mg per kg per day.

Plan is to start on lower dose, around 0.2mg per kg per day which is apparently the physiological dose.

I'm reluctant to throw zycortal at this dog just yet, from what I've read most of these do well on low dose pred so we'll see.

Slightly seething as a colleague did the acth stim and used the whole £40 bottle!

RE: Hypoglycaemia in a 5yo dog

Anthony Dennison — Thu, 03 May 2018 07:54:22 GMT

[quote user="David Mills"]

Update on this case. Stable on preds but looking iatrogenic Cushing. Stopped for 2 weeks, return of lethargy but not hypoglycemic.

ACTH stim

Base <27

Post <27

Electrolytes normal.

So looking v much like atypical Addisons.

[/quote]

Also, although you stopped the preds for 2 weeks as there were signs of Iatrogenic Cushings could this still be adrenal suppression from treatment?

RE: Hypoglycaemia in a 5yo dog

Anthony Dennison — Thu, 03 May 2018 07:53:08 GMT

At LVS last year they were recommending very low levels of preds in Addisonians - 0.1-0.2mg/kg if I remember, though that could have been as low as 0.01-0.02mg/kg.

RE: Hypoglycaemia in a 5yo dog

Sarah Keir — Thu, 03 May 2018 07:39:26 GMT

Zycortal is almost entirely mineralocorticoid in effect, which is why normal/classic hypoadrenocorticism cases require low does preds as well as Zycortal. The dose for these is really low so perhaps you suggestion of lowering the pred dose is good one? I find the DECHRA dose of preds to be used with Zycortal too high for most dogs and they end up getting weaned down. Remember it needs to be given daily as it is hormone replacement, don't be tempted to go to EOD, and at times of stress be prepared to increase it.

RE: Hypoglycaemia in a 5yo dog

David Mills — Wed, 02 May 2018 23:17:37 GMT

Update on this case. Stable on preds but looking iatrogenic Cushing. Stopped for 2 weeks, return of lethargy but not hypoglycemic.

ACTH stim

Base <27

Post <27

Electrolytes normal.

So looking v much like atypical Addisons.

Question is this. I suspect this dog has an isolated glucocorticoid deficiency rather than mineralocorticoid or at least a majority glucocorticoid.

So. Treatment. I am tempted to go with lower dose preds but I am wondering about zycortal as a trial?

RE: Hypoglycaemia in a 5yo dog

Roland Bulkyn-Rackowe — Fri, 09 Feb 2018 11:14:55 GMT

Check bile acid stimulation test in case a shunt or microvascular dysplasia? I usually do these as an outpatient as I'm not convinced that we get good gallbladder contraction when they're hospitalised.

RE: Hypoglycaemia in a 5yo dog

Rach — Thu, 08 Feb 2018 19:37:30 GMT

Another musing I’m afraid, which may not provide any answers, but if the mode of action of preds in hypoglycaemia cases is insulin antagonism, and the dog has responded (clinically and normoglycaemia) despite apparently not having high insulin levels then either:

1. The dog was improving anyway regardless of the pred

2. The pred has had a different mode of action than above (I was going to suggest that maybe it was the small mineralocorticoid activity of pred, supporting the atypical Addison’s theory but... then I tried to look up the pathophysiology of hypoglycaemia in Addison’s, and it would appear that it comes from the loss of Cortisol’s antagonist effect on Insulin, rather than a mineralocorticoid effect. Also, (and definitely getting out of my depth now), but if it were due to a lack of mineralocorticoi, would you not expect the glucose loss to be renal, and you have ruled that out.

Final thought - owners aren’t feeding any jerky treats are they? - there was that spate of cheap Chinese ones causing transient Fanconis syndrome, could a similar effect (i.e. Glucose, rather than protein loss) have happened here and the timing of the urine samples have occurred after they had finished the pack? Yep, clutching at straws!

RE: Hypoglycaemia in a 5yo dog

Martin Atkinson — Thu, 08 Feb 2018 18:23:00 GMT

[quote user="Laurence Webb"]

A random basal cortisol would be a fairly cheap screen for hypoadrenocorticism.

[/quote]Not if its atypical glucocorticoid deficiency only which is what we're talking about here.

RE: Hypoglycaemia in a 5yo dog

Laurence Webb — Thu, 08 Feb 2018 18:06:19 GMT

A random basal cortisol would be a fairly cheap screen for hypoadrenocorticism. If it's subnormal then the cost of an ACTH stim test would be more justified. The preds would be a problem for a sample now, so you'd need to stop them unless there were some of the pre-treatment blood stored still

RE: Hypoglycaemia in a 5yo dog

Martin Atkinson — Thu, 08 Feb 2018 13:59:42 GMT

[quote user="Laura Marshall"]

I have used 17-OHP in the diagnosis of atypical hyperadrenocorticism, but not heard of it for atypical hypoadrenocorticism.

[/quote]Maybe I'm getting my wires crossed then, I was desperately looking for the CPD notes I had on this but couldn't find them.

RE: Hypoglycaemia in a 5yo dog

Laura Marshall — Thu, 08 Feb 2018 13:22:08 GMT

I have used 17-OHP in the diagnosis of atypical hyperadrenocorticism, but not heard of it for atypical hypoadrenocorticism.

RE: Hypoglycaemia in a 5yo dog

Martin Atkinson — Thu, 08 Feb 2018 09:55:43 GMT

[quote user="David Mills"]Atypical Addisons is an interesting avenue, [/quote]I was thinking the same although these usually present as acute GI cases and lack of a stress leukogram. You probably know that you're better looking for 17-OH Progesterone than cortisol levels for these but you still need an ACTH stim test. It is interesting that the insulin is very low as well as the glucose which gives the impression that the islets are doing their best to overcome the hypoglycaemia but insulin is being absorbed into the cells faster than it can be produced. I hadn't considered this as a feature of atypical Addisons but it could be. Alternatively maybe there is some weird autoimmune disease that is producing anti-insulin antibodies.

Given lack of resources and the response to corticosteriods I might be inclined to continue as you are after a discussion with the client that this is a likely diagnosis/treatment protocol and give them the choice of funding the procurement of some Synacthen.

RE: Hypoglycaemia in a 5yo dog

David Mills — Wed, 07 Feb 2018 22:30:29 GMT

[quote user="Rach"]

Not sure I can help much, but this is a list of ddxs from some notes I have (appreciate, most, if not all, you have already ruled out)

Incorrect anticoagulant/delayed separation of serum from RBC

Excessive insulin administration

insulinoma

Extra-pancreatic tumours, esp hepatic tumours

Liver disease

Septicaemic or endotoxic shock

Addisons

Working dogs - idiopathic

Severe polycythaemia

[/quote]

Thank you, for this and continued interest.

Atypical Addisons is an interesting avenue, though we don't have synacthen due to cost (and on preds). Probably liver scan on the list (at least dom/torb will spike the glucose) though unsure how would change tx.

RE: Hypoglycaemia in a 5yo dog

David Mills — Wed, 07 Feb 2018 22:26:30 GMT

[quote user="Robin Grimmer"]

Toy breed hypoglycaemia

[/quote]

Maybe. Never seen it in a 5yo as a first presentation or in a JRT though, have others? Any insights on what causes this toy breed thing?

Interestingly, still being fed same time/frequency so maybe something to look at (case inherited today).

RE: Hypoglycaemia in a 5yo dog

Robin Grimmer — Wed, 07 Feb 2018 21:40:40 GMT

Toy breed hypoglycaemia

RE: Hypoglycaemia in a 5yo dog

Rach — Wed, 07 Feb 2018 20:53:33 GMT

Not sure I can help much, but this is a list of ddxs from some notes I have (appreciate, most, if not all, you have already ruled out)

Incorrect anticoagulant/delayed separation of serum from RBC

Excessive insulin administration

insulinoma

Extra-pancreatic tumours, esp hepatic tumours

Liver disease

Septicaemic or endotoxic shock

Addisons

Working dogs - idiopathic

Severe polycythaemia

RE: Hypoglycaemia in a 5yo dog

David Mills — Wed, 07 Feb 2018 19:30:48 GMT

[quote user="Rach"]

Apologies, I have tried, and failed, to quote you, but but does it definitely rule it out? This is a genuine question, although something way, way at the back of my brain must have sparked this, but can insulin release from an insulinoma be variable? Hopefully someone more intelligent than I will be able to answer this one!

Also were the bloods taken before preds were started?

[/quote]

According to the lab it does pretty much when at these levels, but there are always anomalies one presumes. Non-starved samples. Insulin too low to be measurable essentially.

All bloods except recent bgs well before preds.

RE: Hypoglycaemia in a 5yo dog

Rach — Wed, 07 Feb 2018 19:25:39 GMT

Also were the bloods taken before preds were started?

RE: Hypoglycaemia in a 5yo dog

David Mills — Wed, 07 Feb 2018 19:13:43 GMT

[quote user="Rach"]

What were the actual glucose and insulin readings, if the dog is hypoglycaemic, even an insulin level within the reference range would be abnormal, not sure if the ratio mitigates this at every level...

[/quote]

Insulin <3uIU/ml (11.6-29.0)

Glucose 1.1mmol/L

So rules out insulinoma really.

[quote user="Jenny Boyd"]can you check a urine sample for glucose in the unlikely event of primary renal loss?[/quote]

Urine samples each time, glucose -ve.

BG readings at admission 1.1-1.9mmol/L.

At rechecks whilst on preds (0.5mg/kg) 5.9, 6.2, 6.9

No change in diet, lives with one person. Not an athletic dog, Chihuahua/JRT/something else cross, about 5kg. Onset in mid-January, no previous illness.